The Use of Bovine Serum Albumin and Zephyr Endobronchial Valves for Managing a Bronchial-Biliary Fistula: A Novel Approach

ntroduction: A bronchobiliary fistula (BBF) is a rare pathological communication between the biliary tract and the bronchial tree. It is most often associated with hepatic tumours, infections or trauma. The diagnosis can be challenging; management strategies vary and include conservative, surgical and endoscopic approaches. Case description: A 61-year-old woman with metastatic colorectal cancer to the liver –managed with hepatic resections and ablation – presented with progressive dyspnoea and a productive cough. She had a recent history of pyogenic liver abscess treated with antibiotics. A computed tomography (CT) scan revealed a persistent hepatic abscess with a fistulous tract to the right middle lobe. Bronchoscopy confirmed bilious secretions from the right middle lobe. Initial management with endobronchial BioGlue application resulted in temporary improvement; however, recurrence occurred within eight days. A bronchoscopy was then repeated with additional BioGlue applied, and a 5.5 Zephyr endobronchial valve was deployed into the right middle lobe. The proximal orifice of the valve was sealed with BioGlue to ensure occlusion. This combined approach resulted in improved oxygenation and cessation of air leak from the biliary drain. Despite successful fistula closure, the patient succumbed to candida fungemia. Conclusion: BBF remains a challenging condition with no standardised management guidelines. This case represents the first reported use of BioGlue® in combination with a Zephyr® endobronchial valve for successful endobronchial closure of a bronchobiliary fistula. Our experience highlights the potential of innovative bronchoscopy interventions as minimally invasive alternatives to surgery in select patients.